Revisions to the Track Record (Look-back Period)

The new requirements for the organization track record (look-back period) for initial and triennial surveys went into effect on 1 January 2018. The changes are intended to encourage organizations that are starting on the JCI accreditation journey to be well prepared. At the same time, JCI expects organizations that have received JCI accreditation to implement policies, procedures, and processes that support continuous compliance with the standards as well as year-round data collection and recordkeeping.

What does this mean?

Hospitals and academic medical center (AMC) hospitals that undergo their initial survey on 1 January 2018 or later are now required to have a six-month track record (increased from the current requirement of four months).

For hospital / AMC hospital triennial surveys conducted between 1 January 2018 and 31 December 2020, the 12-month look-back requirement remains in effect. This means that for any surveys that take place between 1 January 2018 and 31 December 2020, the surveyors will look back over the previous 12 months for compliance data.

Starting 1 January 2021, the 12-month look-back period for triennial surveys will be retired. Instead, the look back period will extend to the last day of the organization’s previous full or follow-up survey. This means that for any triennial survey conducted on or after 1 January 2021, JCI surveyors may look as far back as the date of the organization’s previous survey for compliance data.

Can you give me more examples?

1)Hospital X is doing their initial survey that begins 5 February 2018 and ends 9 February 2018. The surveyors will look back 6 months. However, beginning the day after the survey (10 February 2018), the organization will need to show continual compliance with the standards. Thus, when the organization has their triennial survey beginning 5 February 2021, the surveyors may look back to 10 February 2018 for evidence of compliance.

2)Hospital Y is an AMC hospital whose triennial survey begins 27 December 2020 and ends 31 December 2020. The look-back for the survey that begins 27 December 2020 is 12 months. However, beginning 1 January 2021, the organization will need to show continual compliance with the standards. Thus, when the organization has their triennial survey beginning 27 December 2023, surveyors may look back to 1 January 2021 for evidence of continual compliance with the standards.

3)Hospital Z is doing their initial survey on 1 March 2018 and ends 5 Feb 2018. The organization required a follow-up survey, which was conducted on 11 July through 13 July 2018. When the organization has their triennial survey beginning 28 February 2021, surveyors may look back to 14 July 2018 for evidence of continual compliance with the standards.

What should we do?

If you have an upcoming survey, be aware of the correct track record period for your organization’s survey. If you have questions please contact your JCI Accreditation Account Executive or submit your questions via email to jciaccreditation@jcrinc.com.

For hospitals and AMC hospitals that have completed initial or triennial surveys on or after 1 January 2018, remember that the organization now needs to be compliant with the standards on a continuous basis beginning the day after the accreditation survey.